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CURRENT OPINION
A longer version of this article has been published in European Journal of Heart Failure and is available at http://onlinelibrary.wiley.com/doi/
10.1002/ejhf.289/full1
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
* Corresponding author. Tel: +33 149958072, Fax: +33 149958071, Email: alexandre.mebazaa@lrb.aphp.fr; alexandre.mebazaa@lrb.ap-hop-paris.fr
Published on behalf of the European Society of Cardiology. All rights reserved. & European Society of Cardiology 2015. For permissions please email: journals.permissions@oup.com.
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Acute heart failure is a syndrome in which emergency physicians,
cardiologists, intensivists, nurses, and other healthcare providers
have to cooperate to provide rapid benefit to the patients. We
hereby would like to underscore the wider experience grown in different settings of the area of intensive care on acute heart failure, actually
larger and more composite than that got in specialized Care Units. The
distillate of such different experiences is discussed and integrated in the
present document. Hence, the authors of this consensus paper believe
a common working definition of AHF covering all dimensions and
modes of presentations has to be made, with the understanding that
most AHF presentations are either acute decompensations of
chronic underlying HF or the abrupt onset of dyspnoea associated
with significantly elevated blood pressure. Secondly, recent data
show that, much like acute coronary syndrome, AHF might have a
time to therapy concept. Accordingly, pre-hospital management is
considered a critical component of care. Thirdly, most patients with
AHF have normal or high blood pressure at presentation, and are
A. Mebazaa et al.
admitted with symptoms and/or signs of congestion. This is in contradiction to the presentation where low cardiac output leads to symptomatic hypotension and signs/symptoms of hypoperfusion, a
circumstance that is relatively rare, present in coronary care unit/
intensive care unit (CCU/ICU) but associated with a particularly
poor outcome. Hence, it is important to note that appropriate
therapy requires appropriate identification of the specific AHF phenotype.3 The aim of the current paper is not to replace guidelines, but, to
provide contemporary perspective for early hospital management
within the context of the most recent data and to provide guidance,
based on expert opinions, to practicing physicians and other healthcare professionals (Figure 1). We believe that the experience
accrued in the different settings from the emergency department
through to the ICU/CCU is collectivel valuable in determining how
best to manage the patients with AHF. Herein, a shortened version
mainly including group recommendations is provided. Full version of
the consensus paper is provided as Supplementary material online.
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on July 12, 2016
Figure 1 Algorithm for the management of acute heart failure. AHF, acute heart failure; VAS, Visual Analogue Scale for dyspnea assessment; RR,
respiration rate; SpO2, blood oxygen saturation; HR, heart rate; ICU, intensive care unit; Cathlab, cardiac catheterisation laboratory; CCU, coronary
care unit; IV, intravenous; SBP, systolic blood pressure; cTn, cardiac troponin, th, therapy, ACS, acute coronary syndrome.
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Figure 1 Continued.
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Table 1
A. Mebazaa et al.
Clinical characteristics of the AHF patients according to the different sites of initial contact and management
Admission site
Cardiac ICU/CCU
Emergency department
Pre-hospital setting
Euro-HF II
n 5 3580
ADHERE
n 5 159 168
Ducros et al.
n 5 207
................................
EFICA
n 5 599
....................................
ATTEND
n 5 1100
.........................................
Sporer et al.
n 5 319
...............................................................................................................................................................................
Male (%)
61
59
49
59
41
47
Age (years)
SBP . 140 mmHg at admission (%)
70
63
73
60
73
74
72
71
81
75
77
77
3.9
29
NA
Initial SBP
135
126
144
147
170
167
Figure 3 Oxygen and ventilatory support in acute heart failure. PS-PEEP, pressure support-positive end-expiratory pressure. CPAP, continuous
positive airway pressure; RR, respiration rate; SpO2, oxygen saturation.
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Oxygen therapy should be considered in patients with AHF having
SpO2 , 90%
Non-invasive ventilation (NIV) is indicated in patients with
respiratory distress and should be started as soon as possible.
Non-invasive ventilation decreases respiratory distress and also
reduces the rate of mechanical endotracheal intubation
Management of evidence-based
oral therapies
In case of decompensation of CHF, every attempt should be made
to continue evidence-based, disease-modifying, oral therapies in
patients with AHF (Table 3).
In the case of de novo HF, every attempt should be made to initiate
these therapies after hemodynamic stabilization.
Table 2
New-onset HF or no maintenance
diuretic therapy
Furosemide 40 mg intravenous
A. Mebazaa et al.
No change
Stop
Review
No change
Stop
No change
CCB, calcium channel blockers (mg/dL); Cr, creatinine blood level (mg/dL); eGFR, estimated glomerular filtration rate ml/min/1.73 m2; MRA, mineralocorticoid receptor antagonist; (*) amiodarone.
No change
No change
Review/stop (*)
Stop
Reduce/stop
Review
Other heart rate slowing drugs
(amiodarone, CCB, Ivabradine)
Reduce/stop
Stop
Reduce
No change
No change
Stop
Review/increase
No change
Review/increase
Review/No change
No change
No change
No change
No change
No change
No change
No change
Stop
Stop
Stop
No change
Diuretics
Other vasodilators (Nitrates)
Reduce
Reduce/stop
No change
Increase
Increase
MRA
Review
No change
Stop
No change
Review/increase
No change
ACE-I/ARB
Beta-blocker
Reduce/stop
Reduce/stop
Stop
Stop
No change
Reduce
No change
Stop
Review/increase
No change
Cr < 2.5,
eGFR > 30
<3.5 mg/dL
<50 bpm
<85 mmHg
>5.5 mg/dL
Cr > 2.5,
eGFR < 30
.............................................................................................................................................................................................................................................
<60
>50 bpm
<100
>85 mmHg
Potassium
Renal impairment
Hypotension
Normotension/
hypertension
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.....................................
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Supplementary material
Supplementary material is available at European Heart Journal online.
Funding
K.D. is supported by the Netherlands Heart Institute (ICIN) and an ESC
HFA Research Grant.
Conflict of interest: A.M. received speakers honoraria from Alere,
Bayer, Edwards Life Sciences, The Medicines Company, Novartis,
Orion, Servier, Thermofisher, Vifor Pharma and also received fee as
member of advisory board and/or Steering Committee from Bayer,
Cardiorentis, The Medicine Company, Critical Diagnostics.
M.B.Y. received speakers honoraria and research fee from Novartis
and received fee as Steering Committee member of Cardiorentis, and
is supported by TUBITAK.
P.L. received speakers honoraria from Beckman Coulter and Novartis
and also received fees as a member of advisory board and/or Steering
Committee from Bayer, Cardiorentis, The Medicines Company, Cornerstone Therapeutics, Novartis, Otsuka, Janssen, Apex Innovations, InteSection Medical, and Trevena.
P.P. received speakers honoraria from Bayer, Novartis, Servier, Vifor
Pharma, Amgen, Pfizer, Cardiorentis, Merck-Serono, Abbott Vascular
and Respicardia and also received fee as member of advisory board
and/or Steering Committee from Bayer, Cardiorentis, Novartis, Vifor
Pharma Ltd, Amgen, Servier, Abbott Vascular, Coridea and Respicardia.
W.F.P. received research grants from Abbott, Alere, Banyan, Cardiorentis, Portola, Roche, The Medicines Company, served as a consultant
for Alere, BG Medicine, Beckman, Boehringer-Ingelheim, Ardiorentis, Instrument Labs, Janssen, Prevencio, The Medicines Company, ZS Pharma,
and has ownership interests in Comprehensive Research Associates,
LLC, and Emergencies in Medicine, LLC.
S.L. received speakers honoraria from Roche, and received fee as
member of advisory board from Novartis.
A.R. received speakers honoraria from Servier, Astra Zeneca,
Boehringer-Ingelheim, Abbott, Teva, Richer Gedeon, and Merck-Serono
and fee as a member of advisory board from Boehringer-Ingelheim and
Merck-Serono.
E.L. received consultancy fee from Novartis.
References
1. Mebazaa A, Yilmaz MB, Levy P, Ponikowski P, Peacock WF, Laribi S, Ristic AD,
Lambrinou E, Masip J, Riley JP, McDonagh T, Mueller C, deFilippi C, Harjola VP,
Thiele H, Piepoli MF, Metra M, Maggioni A, McMurray JJV, Dickstein K, Damman K,
Petar M. Seferovic, Ruschitzka F, Leite-Moreira AF, Bellou A, Anker SD, Filippatos
G. Recommendations on pre-hospital & hospital management of acute heart
failure: a consensus paper from the Heart Failure Association of the European
Society of Cardiology, the European Society of Emergency Medicine and the
Society of Academic Emergency Medicine. Eur Heart J 2015;doi: 10.1002/ejhf.289
[published online ahead of print May 22, 2015].
2. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, Falk V,
Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Kober L, Lip GY,
Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Ronnevik PK, Rutten FH,
Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A,
ESC Committee for Practice Guidelines. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and
Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the
ESC. Eur Heart J 2012;33:1787 1847.
3. Follath F, Yilmaz MB, Delgado JF, Parissis JT, Porcher R, Gayat E, Burrows N,
McLean A, Vilas-Boas F, Mebazaa A. Clinical presentation, management and outcomes in the Acute Heart Failure Global Survey of Standard Treatment
(ALARM-HF). Intensive Care Med 2011;37:619 626.
4. Lee DS, Stukel TA, Austin PC, Alter DA, Schull MJ, You JJ, Chong A, Henry D, Tu JV.
Improved outcomes with early collaborative care of ambulatory heart failure
A. Mebazaa et al.
5.
6.
7.
8.
10. Fonarow GC, Heywood JT, Heidenreich PA, Lopatin M, Yancy CW, ADHERE Scientific Advisory Committee and Investigators. Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004:
findings from Acute Decompensated Heart Failure National Registry (ADHERE).
Am Heart J 2007;153:1021 1028.
11. Sato N, Kajimoto K, Asai K, Mizuno M, Minami Y, Nagashima M, Murai K, Muanakata R,
Yumino D, Meguro T, Kawana M, Nejima J, Satoh T, Mizuno K, Tanaka K, Kasanuki H,
Takano T, ATTEND Investigators. Acute decompensated heart failure syndromes
(ATTEND) registry. A prospective observational multicenter cohort study: rationale,
design, and preliminary data. Am Heart J 2010;159:949 955 e1.
12. Ducros L, Logeart D, Vicaut E, Henry P, Plaisance P, Collet JP, Broche C, Gueye P,
Vergne M, Goetgheber D, Pennec PY, Belpomme V, Tartiere JM, Lagarde S,
Placente M, Fievet ML, Montalescot G, Payen D, CPAP collaborative study group.
CPAP for acute cardiogenic pulmonary oedema from out-of-hospital to cardiac
intensive care unit: a randomised multicentre study. Intensive Care Med 2011;37:
15011509.
13. Sporer KA, Tabas JA, Tam RK, Sellers KL, Rosenson J, Barton CW, Pletcher MJ. Do
medications affect vital signs in the prehospital treatment of acute decompensated
heart failure? Prehosp Emerg Care 2006;10:41 45.
14. Anker SD, Ponikowski P, Mitrovic V, Peacock WF, Filippatos G. Ularitide for the
treatment of acute decompensated heart failure: from preclinical to clinical
studies. Eur Heart J 2015;36:715 723.
15. Pitt B, Anker SD, Bohm M, Gheorghiade M, Kber L, Krum H, Maggioni AP,
Ponikowski P, Voors AA, Zannad F, Nowack C, Kim SY, Pieper A, Kimmeskamp-Kirschbaum N, Filippatos G. Rationale and design of MinerAlocorticoid
Receptor antagonist Tolerability Study-Heart Failure (ARTS-HF): a randomized
study of finerenone vs. eplerenone in patients who have worsening chronic
heart failure with diabetes and/or chronic kidney disease. Eur J Heart Fail 2015;
17:224 232.
9.
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